Wiki Coding from just dictation

[mbarbour]

In our hospital, the ER physicians bills seperate from the hospital- we bill for the professional fees only. We do have a coder that codes for just the doctors, she does have the patients record available when she codes-so she can look at the facesheet, etc. Sometimes our doctors do get a little slack and do not put everything they do in the dictation, but they will write it on the facesheet. For my own peace of mind I would like to know if ever audited, will they take a look at the whole chart or just the dictated information?

 

[eadun2000]

When being audited they should be looking at the whole DOS. I have coded some ED with being dictated and they also have the fill in sheets too. As far as I am aware, this is perfectly fine as all is supposed to be looked at in an audit. The levels match the documentation in all documents. I hope this helps.